The Mini-Mental Status Exam- Appropriate for Alzheimer’s Disease?

I have issues with the Mini Mental Status Exam being the go-to, quickie dementia assessment tool used by physicians.  It was designed to be brief (10 minutes at the doctor’s office or bedside at the hospital), and to gently probe into each of the major areas of cognition.  It is simple to score and provides an objective number that can be used as a baseline for cognitive performance.  There is plenty of research touting the MMSE’s high degree of validity and reliability in assessing cognitive function.  But does it really assess for Alzheimer’s disease?  Does it provide any scope of severity of the disease or, more importantly, measure function?

I think not.

What is the MMSE?

The Mini Mental Status Exam per Wikipedia::

The mini–mental state examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia. It is also used to estimate the severity of cognitive impairment and to follow the course of cognitive changes in an individual over time, thus making it an effective way to document an individual’s response to treatment.
In about 10 minutes it samples functions including arithmetic, memory and orientation. It was introduced by Folstein et al. in 1975.[1] This test is not a mental status examination. The standard MMSE form which is currently published by Psychological Assessment Resources is based on its original 1975 conceptualization, with minor subsequent modifications by the authors.

Help me up onto this soapbox.  Here’s my beef:

1. The Mini Mental is a language-based tool.  It requires both receptive and expressive language skills.  It is obvious that anyone with Alzheimer’s disease will score poorly on the exam for this reason alone.  It fails to actually measure attention, executive reasoning, spatial orientation, and motor skills because the methodology handicaps the patient.  It’s as useless as timing a paraplegic in a footrace.
2. I hear your argument… someone who scores poorly on the MMSE  has dementia.  Someone who cannot answer the questions correctly clearly has cognitive deficits.  Except that demented persons can score really well on the MMSE.  He or she can also become highly familiar with it- due to being given the identical assessment on several different occasions.  He or she could also bomb  the test because the doctor has asked him to draw two pentagons and the last time he had to draw a pentagon he was in ninth grade and he hasn’t held a pen in months and oh his handwriting is just terrible and he can’t even see the page that well and before you know it he is a distraught and anxious patient being asked to count backwards from 100 by 7s.  It’s angsty and painful… just like ninth grade.
3. The Mini Mental Status Exam favors the more highly educated.  Over the last 30 years, people have tried to build in mechanisms to adjust for educational levels without reliable success.  My experience is purely anecdotal and highly logical… someone familiar with academics, spelling, math, writing, reading… will do better on this exam despite the presence or severity of dementia.  That’s just the way I see it.
4. Inter-rater reliability is not solid... Dr. Smith scored him at a 24 and prescribed Aricept.  Dr. Jones sees him 6 months later and scores a 25.  Miracle drug or accurate assessment?
5. Does the score even matter?  So what.  So what if your dad scored a 21 and your mother-in-law scored a 27.  Your dad can probably shave himself and heat up a cup of coffee but your mother-in-law pays the same electric bill three times.  My point is, the MMSE provides no insight into the functional status of someone with dementia.  The score doesn’t reflect what skills are still intact, or how certain functional tasks are impacted.  It is not a good tool for measuring the effectiveness of medication or the incidence of difficult behaviors.  It is useless for both the healthcare professional and the caregiver.

The MMSE is a tool of convenience.  I understand why physicians, nursing homes, assisted living facilities, and psychologists reach for the single page exam as routinely as they reach for prescription pads.  It’s  a habit.

There are so many assessment tools out there- some complicated to administer and some quick and easy.  The problem with assessing Alzheimer’s is that the only way to see how the disease is affecting the brain is to see the big picture… how successful the person is in performing highly familiar tasks versus new learning, the presence/incidence of psychiatric features (delusions, paranoia, agitation, depression), the amount of support and the environment he or she functions in.

The validity of using the mini mental state examination in NICE dementia guidelines

The Journal of Neurology, Neurosurgery, and Psychiatry with Practical Neurology